Gratitude and Compassion

Tired of caring? You may have compassion fatigue

Do you have trouble remembering what drew you to nursing? Do you take alternative paths through the unit to avoid running into a patient’s family members? Do your colleagues get on your last nerve? Are you ashamed of how you’ve started to feel about your patients, coworkers, family—and the world?Discontentment is a normal part of the human experience. But if you’re overwhelmed by negativity and getting little to no enjoyment from your life or career, you may be suffering from compassion fatigue—and you need to pay attention to those symptoms now. (See Why nurses are at high risk by clicking the PDF icon above.)

A persistent problem

In 1992, Carla Joinson coined the term compassion fatigue to describe an emotionally devastating form of burnout experienced by many in caregiving professions—from physicians and nurses to social workers, first responders, and 911 operators.

More than 20 years later, the condition has been heavily researched but continues to affect many nurses. A 2009 review of 57 studies of compassion fatigue conducted between 1992 and 2006 found that while often confused with burn¬out, the phenomenon takes a real toll on caregivers, patients, and other healthcare workers.

Is it compassion fatigue or job burnout?

Compassion fatigue usually occurs when nurses form such close interpersonal relationships with suffering patients that the nurse-patient boundary becomes blurred. The nurse may unconsciously internalize the distress being experienced by one or more patients. The onset of compassion fatigue may be sudden (for instance, with the death of a single patient with whom the bond was very strong) or may arise gradually after cumulative losses.

Burnout, on the other hand, typically stems from ongoing workplace conflicts. Such conflicts can take the form of horizontal hostility between nurses, conflicts with nurse supervisors, unmanageable time demands and patient loads, dissatisfaction over making less money than other healthcare practitioners, and more. Ultimately, burnout is about career and job dissatisfaction, whereas compassion fatigue centers around the nurse’s inability to establish personal boundaries against the heartbreaking realities of the nursing profession.

But for many nurses, compassion fatigue and burn¬out go hand in hand. A 2010 study of emergency department nurses found that roughly 82% had moderate to high levels of burnout and nearly 86% had moderate to high levels of compassion fatigue.


Symptoms of compassion fatigue

Nurses suffering from compassion fatigue often bottle up their emotions rather than talk about them. Over time, this can lead to mental and physical exhaustion, apathy, sadness, loss of enjoyment from activities once found pleasurable, and other symptoms similar to those of posttraumatic stress syndrome. Symptoms may begin to show up as physical and behavioral changes, including the tendency to:

  • blame others for one’s problems
  • be overly negative
  • self-medicate with drugs or alcohol to mask emotions
  • isolate oneself from coworkers, friends, and family
  • engage in compulsive behaviors (such as overspending, overeating, gambling, and sex addiction)
  • experience nightmares and flashbacks
  • neglect personal appearance and hygiene.

In some nurses, compassion fatigue may self-correct or occur intermittently. For others, it can lead to performance referrals for excessive absenteeism, tardiness, negative feedback as a result of poor performance or attitude, or mistakes due to inattention or distraction. If compassion fatigue isn’t addressed early, it can permanently alter a caregiver’s ability to provide compassionate care. Unfortunately, because of many nurses’ reluctance to even acknowledge they need help, they may wait until a crisis occurs to confront the problem.

Addressing compassion fatigue

Nurses who try to address their compassion fatigue by “caring less” about what happens to their patients may end up with less favorable patient outcomes and reduced career satisfaction. Those who receive performance referrals for behaviors linked to compassion fatigue may fear their careers are over. But in some ways, those who are brought to their knees by compassion fatigue are better off than those who spend their entire careers overidentifying with patient suffering and struggling with low-level symptoms of compassion fatigue.

Preventing compassion fatigue

Many nurses are reluctant to talk about themselves and feel guilty spending a lot of time thinking about themselves. Some rarely make the time to take care of their own needs. Addressing issues as they come up rather than letting them accumulate and fester is a better approach to preventing compassion fatigue. Many organizations have established support systems for nurses and physicians and have provided a forum where they can discuss the emotional issues surrounding caring for terminally ill and suffering patients.

For instance, providing nurses with opportunities to debrief from especially emotional events and losses helps raise their awareness of their needs and feelings. It also underscores the importance of getting support from others. If your organization doesn’t have a program like that available, ask your supervisor or human resources department if one could be started. A debriefing program can take many forms, including an informal peer support group that meets regularly or as needed, made up of interested staff members. In some cases, the program might consist of a more formal committee that reaches out after a loss or an adverse event or outcome; training for committee members on how to provide optimal support could be given by internal mental and behavioral health staff or through the facility’s Employee Assistance Program (EAP). The EAP also can offer critical-incident stress debriefings for particularly difficult cases. Finally, more organizations are engaging in Schwartz Center Rounds, where healthcare team members are encouraged to share their thoughts and emotions around particular difficult cases or situations.

Self-care triage

Many nurses hear “Yadda, yadda, yadda” when people talk about maintaining a work-life balance. They think, “That may be nice for others, but I don’t have the time.” Nurses with this attitude may find themselves defenseless against compassion fatigue.

Exercise and attention to nutrition are central to work-life balance. Don’t be like the patients who tune out your discharge orders. If you care about your patients and family, show it by paying attention to your own health and well-being.

Nurse peer coaching

Nurse peer coaching has provided welcome relief for many nurses. A conversation with someone who’s walked in your shoes and can be trusted with your confidences can give needed perspective and permission to do what you need to do yourself. A nurse peer coach can walk you through your day and point out opportunities for mindfulness, meditation, and exercise.

Peer coaching also can help you brainstorm ways to avoid or work around situations you know will be painful to you or to figure out why you continue to engage in behaviors you know will be unpleasant. Is there a payoff you can’t see? Is there some way to approach this situation that will yield less pain and more gain? If your facility refers you to its EAP or an affiliated counselor, chances are you’ll be given time and opportunity to learn the skills and perspectives that can help you resolve your symptoms and prevent them from advancing—or from occurring in the first place.

Case study: From performance referral to a more joyful life

PJ was devastated when she was referred to her hospice organization’s EAP. When making the referral, her supervisor noted PJ had been exhibiting diminished efficiency and a decline in attitude. While the intent was to get PJ the support she needed, PJ viewed the referral as a disciplinary action. She felt an enormous sense of failure.

A youthful mother of two who commuted an hour each way to her full-time job caring for terminally ill patients, PJ had plenty of time to measure her performance as a mother against that of her own “super mom,” who’d managed an entire household and full-time work with seeming ease. During EAP intake, PJ admitted that the stress of losing patients combined with her sense of failure as a mother and a housekeeper had left her feeling depressed, tired, irritable, and inadequate. The harder she tried, the worse she felt. And now, with this referral, her self-esteem had taken a hit.

After four sessions with a nurse peer coach, PJ was able to adjust her goals to be more in line with who she was and what she needed. She learned to identify boundaries she could feel good about setting. She was fortunate to have a supportive environment at home and work, so her boundaries were respected. As a result, implementing her new boundaries wasn’t a struggle.

In her last nurse peer session, PJ reported having more energy, improved self-esteem, and a greater enjoyment of life than she’d had even before the onset of her difficulties. For her long commutes, she has replaced the “tapes” of her personal and professional failures that used to play in her head with joy and enthusiasm for her day.

Whether you’re forced to get help like PJ was, or you reach the point where you acknowledge things have to change, you can learn how to recognize symptoms of compassion fatigue and manage them. Eventually, you’ll able to care for others without hurting yourself.

Click here for a complete list of references.

The authors work at Midwest EAP Solutions in St. Cloud, Minnesota. Julie Boertje is a nurse peer coach. Liz Ferron is a senior EAP consultant.

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